II. Accountability: Report on PEPFAR Partnerships for Prevention, Treatment and Care

	Partnerships for Prevention The world cannot defeat this pandemic through treatment and care alone. The UNAIDS 2008 Report on the Global AIDS Epidemic estimates that there were approximately 2.7 million new HIV infections in 2007. This indicates that new infections still far outpace the world's ability to add people to treatment. The best approach to the challenges posed by HIV/AIDS is to prevent infection in the first place. Without effective prevention, the growing number of people in need of treatment and care and the growing number of OVCs will overwhelm the world's ability to sustain its response. Recognizing this, PEPFAR supports the most comprehensive, evidence-based prevention program in the world, targeting interventions based on the epidemiology of HIV infection in each country. In the focus countries in FY2008, PEPFAR provided $712 million to support prevention activities that focus on sexual transmission, mother-to-child transmission, the transmission of HIV through unsafe blood and medical injections, and male circumcision. This investment represented 22 percent of program funding in the focus countries; if counseling and testing is counted as prevention (as most international partners do, and as PEPFAR will beginning in FY2009), this share increases to 29 percent. PEPFAR also integrates new prevention methods and technologies as evidence is accumulated and normative guidance provided. In recent years the evidence of declining HIV prevalence and incidence as a result of changes in sexual behavior has grown significantly. UNAIDS has stated that, "this reduction in HIV incidence likely reflects natural trends in the epidemic as well as the result of prevention programmes resulting in behavioural change in different contexts." This finding reinforces the importance of comprehensive support for sexual behavior change. However, as demonstrated by the lack of decline in new infections, there is still a tremendous amount of work to be done. In many cases, programs are still using prevention techniques developed 20 years ago. It is important for prevention activities to enter the 21st century and keep pace with evidence-based techniques and modalities that have been developed to change human behavior, especially those developed in the private sector for commercial marketing.
Combination prevention There is also a clear need for concentrated prevention efforts that mirror progress in treatment. Just as combination therapy revolutionized treatment, combination prevention is needed to revolutionize behavior change programs. Combination prevention includes both biomedical and behavioral interventions, and uses different modalities to affect behavior change depending upon the epidemiological, social, and cultural drivers of transmission in a given geographic region. Wherever people are, prevention programs must be there to meet and empower them with appropriate knowledge and skills. For example, many youth hear prevention messages in church or in school, but then hear conflicting messages from their peers. Still other youth have no access to either school or church; therefore, in order to reach all youth, prevention programs must blanket geographic areas with varied prevention modalities to ensure that all youth can hear the messages and change their behavior accordingly. As part of this effort to implement innovative prevention programs and evaluate their impact, PEPFAR is working to "modularize" successful prevention programs so that the components found to be most effective and easy to transfer to other geographic areas can be rapidly replicated, adapted, and scaled up. A prime example is the recently launched Partnership for an HIV-Free Generation, a new global PPP. Through the Partnership, leaders from the private sector are joining forces with the public sector and NGOs to revolutionize HIV prevention for youth aged 10-24 years by creating a social movement. The Partnership will pursue combination prevention strategies that surround youth with age-appropriate behavioral, structural, and biomedical interventions under a unifying brand. Combination prevention will parallel the intensity, focus, and success of combination ART -integrating social and behavioral change with proven scientific and medical methods. Nairobi, Kenya, serves as the pilot site to refine the partnership model and youth-focused HIV prevention strategies. Interventions will then spread to reach youth in other PEPFAR-supported countries. PEPFAR has also developed the Southern Africa Prevention Initiative (SAPI) to strengthen prevention programming across the region. Southern Africa remains the epicenter of the epidemic, accounting for approximately 35 percent of all PLWHA and almost a third of all new infections and deaths globally. With its nine countries - Botswana, Lesotho, Malawi, Mozambique, Namibia, South Africa, Swaziland, Zambia, and Zimbabwe - consistently reporting adult prevalence rates between 14 percent and 34 percent, it is clear that Southern Africa has a critical need to adopt more strategic HIV prevention approaches to reduce the number of new infections. Through SAPI, PEPFAR is implementing a comprehensive training package for prevention. The objective is to strengthen the technical expertise to design, implement, monitor, and evaluate prevention programs that are based on the principles of HIV prevention, including: theories of behavior change; updates on recent literature on prevention approaches; the analysis and interpretation of surveys, surveillance, and studies; intervention design and implementation; methods to select and adapt interventions for country use; identifying national prevention priorities; prevention policy and advocacy; and monitoring and evaluation of HIV prevention programs. The trainings include both academic theory and implementation of HIV prevention and incorporate biomedical and community-based interventions. In addition, PEPFAR is continuing to create effective approaches for older populations, including discordant couples, and is implementing them in the same geographic locales as the youth programs. Effectively reaching these populations demands the use of sexual behavior change messages and biomedical interventions such as male circumcision, as well as work that is outside the traditional realm of public health, such as education and income-generation programs. While programs have made great strides to provide linkages and direct interventions in these areas, combination programs must be evaluated to determine how best to implement them. Programs that might be good for general development but which do not prevent infections in a significant way are the purview of other health and development programs, not those of PEPFAR. Pamoja Mtaani Under the Partnership for an HIV-Free Generation, Warner Bros. Interactive Entertainment and PEPFAR have worked to bring cutting-edge technology together with evidence-based prevention through a video game called "Pamoja Mtaani" ("Together in the Hood"). The game, intended to engage youth through fun interaction, is designed to influence HIV risk perceptions, attitudes, and behaviors among young people in sub-Saharan Africa. "Pamoja Mtaani" is an open world, multi-player PC video game created by Warner Bros. Interactive Entertainment in collaboration with technical experts within PEPFAR. Currently the game can be played at select venues in Nairobi. The game is a pilot that will be evaluated by behavioral change evaluation experts in order to strengthen HIV prevention programming for youth and will then be expanded to other countries as part of the Partnership for an HIV-Free Generation. Warner Bros. worked closely with youth in Kenya, cultural icons, and regional experts to ensure that the elements were authentic. Top East African hiphop artists were tapped to provide relevant and inspirational original music for use exclusively in the game. "Warner Bros. Entertainment is honored to be a partner with the U.S. Government in this worthy and critically important effort to address this global health issue," said Barry Meyer, Chairman and CEO, Warner Bros. Entertainment. "We are proud to contribute our creativity and talent to this effort."
	Male circumcision As another component of combination prevention, PEPFAR is identifying populations for which safe male circumcision is especially promising and, by host country request, prioritizing service delivery to these populations within a comprehensive prevention package. In anticipation of the potential role of safe male circumcision, PEPFAR has been a member of an international male circumcision steering committee led by UNAIDS and WHO. Since 2006 PEPFAR has funded formative and preparatory work within several countries, including assessments of clinical and community preparedness. With the new WHO/UNAIDS recommendations in place, PEPFAR funds were made available to support the delivery of safe male circumcision services, based on requests from host governments and in keeping with their national policies and guidelines. Male circumcision should be safely provided and integrated into, not substituted for, a comprehensive HIV/AIDS prevention program. In FY2007, PEPFAR countries were provided an opportunity to request further funding to support male circumcision activities. Nine countries received funding totaling $15 million. Resources were then allocated to support activities consistent with the WHO/UNAIDS recommendations, such as stakeholder meetings, clinic and community assessments, training, and policy work. Countries ready to initiate service delivery were required to submit a letter from the MoH requesting USG assistance for male circumcision services. In FY2008, PEPFAR support grew, as 13 countries submitted requests for male circumcision activities totaling $26 million. Of that total, $11 million supported direct circumcision service delivery. Total investments are expected to rise to at least $30 million in FY2009. Allocation of funding and support of organizations is competitively determined at the country level and decisions are based on existing agreements, organizational capacity, and technical skills. Many organizations providing male circumcision have past experience with service delivery (some through their own private funding) or have been working in similar areas of intervention. For example, a group that may have worked on health policy may be requested to expand its scope to also address male circumcision. Scale-up of male circumcision presents significant challenges, including the need for human resources and appropriate counseling to prevent risk compensation (in which men engage in more risky behavior because they believe they are completely protected by circumcision). PEPFAR partners make it clear that male circumcision is not a silver bullet, but only one part of a broad prevention arsenal. ABC behavior change education is incorporated into counseling for men seeking circumcision services. PEPFAR is rolling programs out as rapidly as possible, beginning in areas of high HIV prevalence and among those at greatest risk of infection, such as discordant couples in which the woman is HIV-positive, to maximize the impact of this prevention intervention. There is also a need to develop training and quality assurance programs to ensure the safety and effectiveness of male circumcision. As other prevention strategies, such as microbicides or pre-exposure prophylaxis, are identified by normative agencies as effective, PEPFAR will support them as part of a comprehensive prevention strategy. Thanks to PEPFAR's wide network of care and treatment sites, PEPFAR country teams will be able to implement these methods rapidly whenever they become available - demonstrating again the value of integrated programs. Addressing gender issues PEPFAR fully integrates gender issues into its prevention, care and treatment programs, recognizing the critical need to address the inequalities between women and men that influence sexual behavior and the norms that put both women and men at higher risk of infection and create barriers to accessing HIV/AIDS services. PEPFAR supports five key cross-cutting gender strategies that are critical to curbing HIV/AIDS, ensuring access to quality services, and mitigating its consequences. These strategic focus areas are given in Table 6. Activities in support of these focus areas are assessed annually during the COP review process. In FY2008, approximately $1 billion was dedicated to 1,096 activities that included interventions to address one or more gender focus areas. In 2008, three special gender initiatives continued in nine countries to intensify program efforts in the following focus areas: scaling up evidence-based programs to address male norms and behaviors; strengthening services for victims of sexual violence, including post-exposure prophylaxis (PEP); and addressing the community and structural factors that fuel girls' vulnerability to HIV/AIDS. Gender issues are central to many HIV prevention programs, including those focused on young men and women since attitudes about sexual relationships and risk-taking behavior are often developed at a young age. Prevention messages about delayed sexual debut, secondary abstinence, fidelity to a single partner, partner reduction, and correct and consistent condom use (included in ABC interventions) can address unhealthy cultural gender norms among boys, girls, men, and women. The messages provide information on the harmful effects of violence against women, cross-generational sex, and transactional sex as part of media and community-based interventions; promote involvement of men in PMTCT and counseling and testing programs; support women in disclosure of their HIV status to their partner and family; and engage communities and policy makers on the importance of inheritance rights and women's access to productive resources to mitigate the impact of HIV/AIDS. PEPFAR supports the Kenya Federation of Women Lawyers, which provides legal advice to PLWHA concerning rape, sexual assault, and property and inheritance rights. In South Africa and through the Male Norms Initiative in Ethiopia, Namibia and Tanzania, PEPFAR supports the Men as Partners project, which tailors behavior change interventions to redefine masculinity and strength in terms of men taking responsible actions to prevent HIV infection and gender-based violence. In Namibia, PEPFAR supports the Village Health Fund Project, a microenterprise program that provides vulnerable populations, such as widows and grandmothers who care for orphaned grandchildren, with start-up capital for income-generating projects. Prevention of Sexual Transmission Long before PEPFAR was initiated, many nations with generalized epidemics had already developed their own national HIV prevention strategies that included the "ABC" approach to behavior change. Data that pre-date PEPFAR scale up link adoption of all three of the ABC behaviors to reductions in prevalence. To illustrate an example, Figure 17 shows changes in HIV
prevalence and sexual risk behavior in Zimbabwe during the late 1990s and earlier part of this decade. Learning from the evidence, PEPFAR will continue to support all three elements of the evidence-based ABC strategy in ways appropriate to the epidemiology, social and cultural context, and national strategy of each host nation. Funding in FY2008 for sexual transmission prevention in the focus countries totaled $408.2 million, or 12.6 percent of all program funding. Table 7 shows that an estimated 58,344,900 people were reached by community outreach programs promoting ABC and related prevention strategies. Along with its programs that teach correct and consistent condom use for those who are sexually active, the USG seeks to ensure an adequate supply of condoms. Table 8 shows the USG has supplied more than 2.2 billion condoms worldwide from 2004 through December 2008, lending support to comprehensive ABC approaches based on the epidemiology of each country. It is important to note that prevention of sexual transmission is chronic disease management - as is treatment and care. An individual must be reached at an early age to have maximum impact on lifelong behavior, and prevention messages must change in an age-appropriate way to address changes in risk behavior. Prevention programs span from about 10 years of age until the time at which a person is presumed to be beyond risk - i.e., when he or she is no longer sexually active. Efforts must continue unabated across the lifespan to reinforce and maintain safe and personally responsible behavior. For this reason, data on the reach of behavior change messages and condom supply are provided both for FY2008 and cumulatively from FY2004 through FY2008.
	Elements of ABC interventions ABC programs are more complex than the simple acronym suggests, because changing human behavior is a uniquely difficult undertaking. Achieving ABC requires significant cultural changes. Children must be reached at an early age to encourage delay of sexual debut and to minimize their number of partners. It is essential to rapidly expand life skills programs for youth because of the generational impact. Influencing a 10-year-old's future behavior is far easier than changing a 25-yearold's settled behavior. Behavioral impact from programs for children may not immediately be apparent. We must be patient and persistent. These programs influence future behavior and we are only 5 years into PEPFAR's partnerships for a generational approach to prevention. ABC also includes changing gender norms. Partnering with children's parents and caregivers to support their efforts to teach children to respect themselves and others is the best way to promote gender equality. For the ABC approach to be effective it must address the gender dynamics that affect sexual decision-making and strive to reduce sexual coercion, violence, and rape. Through support for delayed sexual debut, secondary abstinence, fidelity to a single partner, partner reduction, and correct and consistent condom use, ABC contributes to changing unhealthy cultural gender norms. It is also essential to reduce stigma against PLWHA and also against those who choose healthy lifestyles. On the other hand, cross-generational sex, including the phenomenon of older men preying on young girls, and sexual violence, should be identified and even vilified. We must also intensify efforts to reduce stigma against women and girls who are victims of sexual violence; strengthen services for them; and ensure that HIV PEP, related medical care, and psycho-social support are accessible to all survivors. Recent PEPFAR-supported efforts include a growing number of interventions with PLWHA. The adoption of healthy living and reduction in risk behaviors among HIV-positive people leads to a substantial improvement in quality of life and a reduction in HIV transmission rates. These prevention efforts aim to mitigate the spread of HIV to sex partners, IDU partners, and infants born to HIV-infected mothers, and to protect the health of infected individuals. For example, in Uganda, a collaborative provider training initiative involving NGOs, community groups, and the Uganda MoH was developed to build capacity of service providers to deliver effective HIV counseling for PLWHA. Organizations and networks of PLWHA worked together to create prevention messages on a variety of topics, including: partner testing; status disclosure; socio-cultural barriers to prevention; HIV discordance; condom use; and managing the "new lease on life" challenges after ART, including dating, marriage and child-bearing. Knowing your epidemic ABC programs must be comprehensive to be effective. They also must be tailored to the contours of each country's epidemic. ABC behavior change should be at the core of prevention programs, but one size does not fit all. PEPFAR takes different approaches, depending on whether a country has a generalized or a concentrated epidemic. In countries with concentrated epidemics where, for example, 90 percent of infections are among persons in prostitution and their clients, the epidemiology dictates a response more heavily focused on B and C interventions. The 2008 bill reauthorizing PEPFAR supports this focus on the epidemiology of each country. The law changed the statutory approach to prevention of sexual transmission of HIV. The original 2003 PEPFAR authorization required the program to ensure that at least 33 percent of all prevention funding was committed to "abstinence-until- marriage" programs. In computing this, PEPFAR counted funding for both the A and B interventions of the ABC approach. Section 503 of the 2008 Reauthorization Act requires the Global AIDS Coordinator to "provide balanced funding for sexual transmission prevention activities for sexual transmission of HIV/AIDS," and to "ensure that activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction are implemented and funded in a meaningful and equitable way in the strategy for each host country based on objective epidemiological evidence as to the source of infections and in consultation with the government of each host country involved in HIV/AIDS prevention activities." The Coordinator is to establish a sexual transmission prevention strategy in each country with a generalized epidemic. If the strategy provides less than 50 percent of funds for activities promoting abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction, the Coordinator is required, not later than 30 days after the issuance of this strategy, to report to Congress on the justification for this decision. Programs or activities that implement new prevention technologies or modalities are not included in this requirement. For example, among the interventions not subject to determining compliance with this requirement are medical male circumcision, blood safety, promotion of universal precautions, investigation of suspected nosocomial infections, microbicides, pre-exposure pharmaceutical prophylaxis to prevent transmission of HIV, and programs and activities that provide counseling and testing or PMTCT interventions. Addressing multiple concurrent partnerships and discordant couples For older adolescents and adults who are sexually active, ABC includes reducing casual and multiple and concurrent partnerships, which can rapidly spread HIV infection through broad networks of people. Multiple and concurrent partnerships are common in many countries hardest-hit by HIV, and PEPFAR supports programs that emphasize partner reduction toward the goal of faithfulness to a single HIV-negative partner. In October 2008, PEPFAR hosted a technical consultation on "Addressing Multiple and Concurrent Sexual Partnerships in Generalized HIV Epidemics." The meeting brought together colleagues from the field, implementing partners, headquarters staff, and prevention experts to deepen understanding of the role of multiple and concurrent sexual partners in the spread of HIV; share emerging programmatic approaches; and build consensus on promising programmatic strategies to address and mitigate multiple and concurrent partnerships. The limitations of current quantitative methods for measuring multiple and concurrent partners was identified as a key issue in this area. For example, DHS data show a strong correlation between multiple partners and sero-prevalence by country, but do not show a similar strong correlation for concurrent partnerships. Statistical modeling, on the other hand, shows that very small increases in the mean number of concurrent partners very significantly increases the connectivity of sexual networks and HIV prevalence. The corollary is that a relatively small number of people who change their behavior could potentially have significant population-level impact. A less obvious but important point is the difference between individual-level and population-level risk. Having concurrent partners increases one's risk of infecting others more than one's own risk of infection. Several attendees from across sub-Saharan Africa shared their experiences with implementing programs focused on reducing multiple and concurrent partnerships. While significant challenges were noted, including low risk perception related to concurrent partnerships, the presentations demonstrated that multiple and concurrent partnerships can be addressed effectively through multisectoral, culturally sensitive programs. The meeting identified challenges and areas for more expansive research including the need to collect more rigorous impact and process data. Findings from the meeting have been shared with field staff, and PEPFAR will continue to build on the continued evidence that the role of multiple and concurrent partnerships is a key component of HIV prevention interventions. Discordant couples, in which one partner is living with HIV and the other is not, are another important focus for intensive HIV prevention interventions. Given the large number of infections occurring through these discordant partnerships, PEPFAR supports efforts to reach discordant couples through a range of different interventions that include: couples HIV testing; behavior change counseling, including on the importance of being faithful and using condoms correctly and consistently; and ensuring that the HIV-infected partner is linked to appropriate care and treatment services, which can lower the likelihood of transmission. Injecting Drug Users (IDUs) Substance use, including injection drugs, is a major means of spreading HIV in many parts of the world. According to UNAIDS, outside of sub-Saharan Africa injecting drug use comprises just under one-third of global HIV transmission. IDUs everywhere are at great risk for infection with HIV, through contaminated needles and syringes, risky sexual practices, and higher rates of STI. With the exception of Vietnam, the PEPFAR focus countries have generalized epidemics driven by sexual behavior, and substance use plays a much smaller role in HIV transmission. PEPFAR therefore invests the most resources in prevention of sexual and mother-to-child transmission, which are the primary drivers of the epidemic globally. PEPFAR has supported national efforts to establish the political support, policy frameworks, and programmatic experience to scale up HIV/AIDS prevention, treatment and care for IDUs. In Vietnam, PEPFAR invested approximately $89 million in FY2008 for programs focused primarily on injecting drug use. Cambodia, China, India, Kenya, Russia, Tanzania, Thailand, Ukraine, and Vietnam plan to carry out activities to target drug users, both injecting and non-injecting, in FY2009. PEPFAR supports three primary approaches to HIV prevention among IDUs: 1) tailoring HIV prevention programs to substance abusers; 2) supporting substance abuse therapy programs for HIV-positive individuals, and in certain cases in pilots for HIV-negative individuals, as an HIV prevention measure; and 3) offering HIV-positive drug users a comprehensive HIV/AIDS treatment program to reduce the risk of transmission. An important emerging strategy that PEPFAR supports for HIV prevention is medication-assisted therapy (MAT), also known as opioid substitution therapy, for IDUs. PEPFAR supports the use of MAT for HIV-positive and HIV-negative IDUs, focusing on HIV-positive IDUs because they represent an especially high-risk population. HIV-positive IDUs pose a risk for transmission of HIV to HIV-negative individuals - including other IDUs - and for fostering drug resistance if they are not adherent to their ART. Regardless of their serostatus, capacity for MAT interventions for IDUs is extremely limited in PEPFAR countries, so prioritizing interventions for HIV-positive individuals is critical. However, where capacity allows it, PEPFAR has begun to pilot HIV prevention programs that include preventing and treating injection drug use in HIV-negative individuals. PEPFAR has supported MAT globally by working first with governments to develop the political acceptance and national policies to permit MAT interventions. However, because the IDU population is heavily stigmatized, MAT interventions are controversial, and not all countries have passed enabling legislation. A significant breakthrough occurred in 2006 when with strong PEPFAR support Vietnam changed its 5-year national HIV/AIDS strategy and passed HIV legislation to legalize MAT for IDUs. In FY2008 PEPFAR launched pilot MAT centers in Vietnam to serve HIV-positive and -negative clients. PEPFAR also launched pilot MAT centers in Ukraine to deliver this therapy to HIV-positive drug users. Prevention of Mother-to-Child Transmission UNAIDS estimates that 370,000 children under the age of 15 became infected with HIV/AIDS in 2007, down from 460,000 in 2001. Approximately 90 percent of these infections were due to mother-to-child transmission. PMTCT is a key element of the prevention strategies of host nations, and PEPFAR has provided support for host nations' PMTCT interventions for women during approximately 16 million pregnancies. Of these, more than 1.2 million women were determined to be HIV-positive and received preventive ARVs, preventing an estimated 237,600 infections of newborns. Table 9 shows that PEPFAR provided $211.2 million in support of PMTCT programs in FY2008, or 6.5 percent of the total program funding in the focus countries. Table 10 shows that access to vital ANC interventions varies across the focus countries. PEPFAR supports host governments' and other partners' efforts to provide PMTCT interventions, including HIV counseling and testing, for all women who attend ANCs. PEPFAR is working to address
obstacles to successful scale-up of PMTCT programs including: 1) failure to adopt and fully implement "opt-out" provider-initiated counseling and testing; 2) lack of integration as a basic part of maternal and child health care; 3) difficulties extending coverage to peripheral and rural sites; and 4) challenges in developing effective linkages with HIV care and treatment services. PEPFAR support has allowed many nations to make significant progress in reaching pregnant women with PMTCT interventions in recent years, often building on programs that pre-dated PEPFAR (Table 10). In other countries, progress has been slower, and the Emergency Plan is supporting these nations in redoubling efforts to close the gap. When comparing results from the first year of PEPFAR in FY2004 to FY2008, all countries have scaled up, and most have dramatically improved availability of PMTCT interventions to pregnant women. Nations have sought to ensure that all women receive the option of an HIV test through pre-test counseling during pregnancy (or at or after delivery, if they do not seek care before delivery). By promoting the routine offer of voluntary HIV testing to ensure that women receive testing unless they opt out, host nations have increased the rate of uptake among pregnant women from low levels to around 90 percent at many sites. Adoption and effective implementation of opt-out testing, rapid testing, and other essential policy changes, is essential for success. For further information on policies relating to HIV testing, please see the section on Counseling and Testing. Prevention of Medical Transmission Ensuring an adequate supply of safe blood is a critical prevention priority. A key part of PEPFAR's health systems strengthening activities has been 5 years of support to improve national blood transfusion services. In FY2008, PEPFAR provided approximately $92.4 million for medical transmission prevention activities in the focus countries, or 2.9 percent of program funds. This included direct support for 5,287 blood-safety service outlets or programs, as well as broader efforts to strengthen blood service management, commodity procurement, infrastructure, and national policies. Over the past 5 years, the 14 countries that received PEPFAR support for prevention of medical transmission have substantially increased total blood collections from low-risk, voluntary, non-remunerated donors and seen a decrease in the prevalence of HIV-infected units. In addition, laboratory capacity in these countries has been strengthened to ensure that all collected units are screened for HIV and other transfusion-transmissible infections. With PEPFAR support, total blood collections have increased in all 14 countries since the start of the program. Further, in 11 of 14 countries collections per 1,000 population per year have also increased since 2003, indicating that countries are moving progressively closer to meeting their annual demand for safe blood. In order to build capacity for a sustainable response into the future, PEPFAR also supported blood safety training or retraining for 9,838 people in FY2008. Ensuring that medical injections are safe for patients, health workers, and communities is also a vital HIV prevention intervention. PEPFAR has supported medical injection safety programs in 16 countries, reaching more than 150,000 healthcare workers since 2004, and is providing essential commodities for safe medical injections.
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